The relationship between hospital volume and mortality following mechanical ventilation in the Intensive Care Unit

BACKGROUND

A number of recent studies in North America and Europe have investigated the relationship between hospital volume and outcomes following mechanical ventilation in an Intensive Care Unit (ICU). All of these studies have revealed an association between worse outcomes and smaller-volume hospitals. This relationship has not been investigated recently in the UK.

METHODS

A retrospective cohort study was performed using data from the Birmingham and Black Country Critical Care Network database. Adult patients who received mechanical ventilation for more than 24 hours from the period from April 1, 1996, to March 31, 2006, were included in the study. The odds ratio for death in the ICU was calculated in relation to the hospital's volume of ventilation. Estimates accounted for clustering within hospitals and were adjusted for patient demographics (sex, age), APACHE II score, year of ventilation, length of ICU stay and urgency status.

RESULTS

A total of 17132 adult patient episodes were included in the analysis. The adjusted odds ratio for death in the ICU following mechanical ventilation for more than 24 hours was 1.11 (95% confidence interval: 0.91 to 1.35; P=0.297).

CONCLUSION

There is no relationship between hospital volume and mortality following mechanical ventilation in the ICU. Further larger prospective studies are needed to confirm this apparent lack of a relationship between hospital volume and mortality following mechanical ventilation in ICUs in a network of hospitals in the UK.

Surveillance for MDR-TB: is there an obligation to ensure treatment for individuals identified with MDR-TB?

This article raises ethical issues that result if individuals, during the course of research to measure the prevalence of drug-resistant tuberculosis, are identified with the disease but are not provided with or referred for appropriate treatment. It draws attention to and applauds recently published World Health Organization guidelines on the subject. Questions posed are: 1) Should treatment be provided for individuals identified through surveillance projects for MDR-TB, whatever their purpose (specific research or 'routine' national prevalence studies)? 2) If treatment availability is a problem, who is responsible for assuring this?

'The average Scottish man has a cigarette hanging out of his mouth, lying there with a portion of chips': prospects for change in Scottish men's constructions of masculinity and their health-related beliefs and behaviours

Men's apparent resistance to recommended health practices and their engagement with 'high-risk' behaviours has been associated with an increased risk of morbidity or mortality. Recent work has highlighted the need to think critically about the health-promoting behaviours that men appear reluctant to engage in, as well as examining those they embrace, and explore the gendered meanings that men attribute to their beliefs and behaviours. This article presents men's discussions of the 'practices of masculinity' and examines their relation to, and implications for, men's health-related behaviours as articulated in 15 focus group discussions (59 participants in total). The data capture both the experiences of men who felt pressured to engage in behaviours that may be harmful to their health in order to appear masculine and the accounts of those who regarded themselves as freer to embrace salutogenic health practices. Less is known about the circumstances that might encourage men to re-think their engagement in performances of masculinity that have potentially detrimental effects on their health. The data presented here suggest that ageing, illness, and fatherhood were some of the experiences that prompted men to re-evaluate their health practices.

In vitro dissolution studies of uranium bearing material in simulated lung fluid

Inhaled uranium (U) bearing material will partially dissolve in the fluid lining of the lung, followed by a combination of retention, re-distribution, and excretion of the U. The rate of dissolution influences the retention time at the site of deposition, and the extent to which the material is available for re-distribution to other tissues. The consequential radiation dose is dependent upon the material distribution in the body and the exposure time to various tissues. The International Commission on Radiological Protection, ICRP 66 [International Commission on Radiological Protection (ICRP), 1994. Human Respiratory Tract Model for Radiological Protection. ICRP Publication 66] recommends the use of experimentally determined solubility coefficients in dose modelling. Material specific absorption parameters allow for better dose estimation than using ICRP default values for F (fast), M (moderate) and S (slow) classifications of U compounds. In vitro dissolution tests were carried out on U material collected from two U mines located in Australia. A static technique was designed in which particle samples were sandwiched between two 0.1-mum pore size membrane filters. The filter sandwich was exposed to a solvent (simulated lung fluid) for selected time intervals, at controlled test conditions for temperature and pH. The collected solution was analysed for U concentration using ICP-MS. The resulting dissolution curves were fitted with a double or triple exponential equation to determine the dissolution coefficients.

Advanced glycation of apolipoprotein A-I impairs its anti-atherogenic properties

AIMS/HYPOTHESIS

AGE contribute to the pathogenesis of diabetic complications, including dyslipidaemia and atherosclerosis. However, the precise mechanisms remain to be established. In the present study, we examined whether AGE modification of apolipoprotein A-I (apoA-I) affects its functionality, thus altering its cardioprotective profile.

MATERIALS AND METHODS

The ability of AGE-modified apoA-I to facilitate cholesterol and phospholipid efflux, stabilise ATP-binding cassette transporter A1 (ABCA1) and inhibit expression of adhesion molecules in human macrophages and monocytes was studied.

RESULTS

The ability of AGE-modified apoA-I to promote cholesterol efflux from THP-1 macrophages, isolated human monocytes and from ABCA1-transfected HeLa cells was significantly reduced (>70%) compared with unmodified apoA-I. This effect was reversed by preventing AGE formation with aminoguanidine or reversing AGE modification using the cross-link breaker alagebrium chloride. AGE-modification of HDL also reduced its capacity to promote cholesterol efflux. AGE-apoA-I was also less effective than apoA-I in stabilising ABCA1 in THP-1 cells as well as in inhibiting expression of CD11b in human monocytes.

CONCLUSIONS/INTERPRETATION

AGE modification of apoA-I considerably impairs its cardioprotective, antiatherogenic properties, including the ability to promote cholesterol efflux, stabilise ABCA1 and inhibit the expression of adhesion molecules. These findings provide a rationale for targeting AGE in the management of diabetic dyslipidaemia.

Effect of a clinical stroke on the risk of dementia in a prospective cohort

OBJECTIVE

To examine the risk and determinants of dementia following a clinically overt stroke in a prospectively followed cohort of elderly subjects.

METHODS

We examined the effect of a clinically detectable stroke on the risk of dementia using prospective data from 335 subjects in the Baltimore Longitudinal Study of Aging, all of whom were cognitively and neurologically normal at entry into the study (mean age at entry 75.1 +/- 4.2 years).

RESULTS

Clinically overt strokes are common in our cohort (cumulative risk by age 90, 15.4%; 95% CI: 10 to 22%) and confer an increased risk of dementia compared to subjects without stroke (odds ratio [OR] 5.55; 95% CI: 2.76 to 11.4). The majority of patients who became demented after a stroke had evidence of mild cognitive impairment preceding the stroke (14 of 19). Moreover, a clinically symptomatic stroke was a major risk factor for the conversion of mild cognitive impairment to dementia (OR 12.4; 95% CI: 1.5 to 99). When cognitive impairment did not precede the stroke, there was no increase in the risk of subsequent dementia. Pathologic data indicate that both vascular and Alzheimer pathology leads to the prestroke impairment.

CONCLUSION

Dementia after stroke may be determined by cognitive impairments that exist prior to the stroke.

Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy

To assess short- and long-term seizure freedom, the authors reviewed 371 patients who underwent anterior temporal lobectomy to treat pharmacoresistant epilepsy. The mean follow-up duration was 5.5 years (range 1 to 14.1 years). Fifty-three percent of patients were seizure free at 10 years. The authors identified multiple predictors of recurrence. Results of EEG performed 6 months postoperatively correlated with occurrence and severity of seizure recurrence, in addition to breakthrough seizures with discontinuation of antiepileptic drugs.

Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy

To assess short- and long-term seizure freedom, the authors reviewed 371 patients who underwent anterior temporal lobectomy to treat pharmacoresistant epilepsy. The mean follow-up duration was 5.5 years (range 1 to 14.1 years). Fifty-three percent of patients were seizure free at 10 years. The authors identified multiple predictors of recurrence. Results of EEG performed 6 months postoperatively correlated with occurrence and severity of seizure recurrence, in addition to breakthrough seizures with discontinuation of antiepileptic drugs.

Immunological and molecular characterization of susceptibility in relationship to bacterial strain differences in Mycobacterium avium subsp. paratuberculosis infection in the red deer (Cervus elaphus)

Johne's disease (JD) infection, caused by Mycobacterium avium subsp. paratuberculosis, represents a major disease problem in farmed ruminants. Although JD has been well characterized in cattle and sheep, little is known of the infection dynamics or immunological response in deer. In this study, typing of M. avium subsp. paratuberculosis isolates from intestinal lymphatic tissues from 74 JD-infected animals showed that clinical isolates of M. avium subsp. paratuberculosis from New Zealand farmed red deer were exclusively of the bovine strain genotype. The susceptibility of deer to M. avium subsp. paratuberculosis was further investigated by experimental oral-route infection studies using defined isolates of virulent bovine and ovine M. avium subsp. paratuberculosis strains. Oral inoculation with high (10(9) CFU/animal) or medium (10(7) CFU/animal) doses of the bovine strain of M. avium subsp. paratuberculosis established 100% infection rates, compared to 69% infection following inoculation with a medium dose of the ovine strain. The high susceptibility of deer to the bovine strain of M. avium subsp. paratuberculosis was confirmed by a 50% infection rate following experimental inoculation with a low dose of bacteria (10(3) CFU/animal). This study is the first to report experimental M. avium subsp. paratuberculosis infection in red deer, and it outlines the strong infectivity of bovine-strain M. avium subsp. paratuberculosis isolates for cervines.

Evaluation of co-morbidity indices in patients admitted for Chronic Obstructive Pulmonary Disease

Background. There is limited and conflicting information on the use of co-morbidity instruments to predict mortality in patients with chronic obstructive pulmonary disease (COPD). Methods. We sought to test the validity of the Charlson Index and another co-morbidity instrument, the Adult co-morbidity evaluation 27 (ACE-27), in patients admitted with COPD exacerbations. Co-morbidity scores were obtained by chart review. Information on mortality was retrieved from the Social Security Death Index. We examined the predictive validity of the Charlson and the ACE- 27 using survival analysis. Results. There were 112 patients eligible for the study. The ACE-27 but not the Charlson predicted survival, after adjusting for age, gender, and smoking history in Cox regression, hazard ratio (95% CI) of 1.99 (1.17-3.39). Conclusions. This study confirms earlier findings that the Charlson Index is not a reliable predictor of mortality in patients with COPD. However, the ACE-27 appears to be useful for predicting survival in this study.

Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit?

AIM

The purpose of our study was to investigate whether reporting of plain chest radiographs affects immediate management of patients admitted to a medical assessment unit.

MATERIALS AND METHODS

During a 3 month period we prospectively evaluated 200 patients who had a plain chest radiograph on admission. After the post on-call ward round, an independent medical specialist registrar reviewed the notes, retrieving relevant clinical details. The plain chest films were reported independently by a trainee radiologist and consultant, reaching a consensus report.

RESULTS

There was 93% agreement between trainee and consultant radiologists (95% CI=89-96%). Seventy percent had documented reports by the on-call medical team. There was disagreement between radiology and medical reports in 49% of reported films (95% CI=40-57%). The radiologist's report led to a direct change in the immediate management of 22 patients (11%).

CONCLUSION

Only 70% of films had documented reports in the clinical notes despite this being a legal requirement. Radiology reporting does cause a direct change in patient management. Chest radiographs of patients admitted to a medical admissions unit should be reported by a radiologist with the minimum of delay.

Halophilic adaptation of protein-DNA interactions

Pyrococcus woesei ( Pw ) is an archaeal organism adapted to living in conditions of elevated salt and temperature. Thermodynamic data reveal that the interaction between the TATA-box-binding protein (TBP) from this organism and DNA has an entirely different character to the same interaction in mesophilic counterparts. In the case of the Pw TBP, the affinity of its interaction with DNA increases with increasing salt concentration. The opposite effect is observed in all known mesophilic protein-DNA interactions. The halophilic behaviour can be attributed to sequestration of cations into the protein-DNA complex. By mutating residues in the Pw TBP DNA-binding site, potential sites of cation interaction can be removed. These mutations have a significant effect on the binding characteristics, and the halophilic nature of the Pw TBP-DNA interaction can be reversed, and made to resemble that of a mesophile, in just three mutations. The genes of functionally homologous proteins in organisms existing in different environments show that adaptation is most often accompanied by mutation of an existing protein. However, the importance of any individual residue to a phenotypic characteristic is usually difficult to assess amongst the multitude of changes that occur over evolutionary time. Since the halophilic nature of this protein can be attributed to only three mutations, this reveals that the important phenotype of halophilicity could be rapidly acquired in evolutionary time.

Extensive and preferential Fas/Fas ligand-dependent death of gammadelta T cells following infection with Listeria monocytogenes

In the spleens of mice infected intraperitoneally with the bacterium Listeria monocytogenes, both alphabeta and gammadelta T cells became rapidly activated, followed by a massive apoptotic death response predominantly within the gammadelta population. The death response involved two major splenic gammadelta T-cell subsets and was Fas/Fas ligand (Fas-L)-dependent. Among T cells isolated from the Listeria-infected spleen, Fas-L was almost exclusively expressed in gammadelta T cells. gammadelta T cells coexpressed Fas and Fas-L, suggesting activation-induced suicide as a mechanism of their death. In vivo treatment with an antibody specific for CD3epsilon induced activation, preferential Fas-L expression and apoptosis of gammadelta T cells, resembling the response pattern in listeriosis, whereas antibodies specific for T-cell receptor-beta (TCR-beta) or TCR-delta did not, suggesting that the complete response seen in listeriosis requires both gammadelta TCR engagement and additional stimuli. L. monocytogenes causes early nonspecific, Fas-independent lymphocyte death in heavily infected tissues. In contrast, the death response described here is selective, Fas-dependent and triggered at low local levels of bacteria, suggesting that it is controlled by interactions with other infection-activated host cells, and perhaps part of a regulatory circuit specifically curtailing gammadelta T cells.

MAOB intron 13 and COMT codon 158 polymorphisms, cigarette smoking, and the risk of PD

BACKGROUND

A polymorphism (G to A transition) in intron 13 of the mitochondrial enzyme monoamine oxidase B (MAOB) gene may modify, alone or by interacting with the catechol-O-methyltransferase (COMT(LL)) genotype (low enzymatic activity), the risk of idiopathic PD. Also, the association between never smoking and PD risk may be present only in people with the MAOB G allele.

METHODS

The authors studied two ongoing prospective cohorts-the Nurses' Health Study (121,700 women aged 30 to 55 in 1976) and the Health Professionals' Follow-up Study (51,529 men aged 40 to 75 in 1986). They identified new PD cases through 1996, selected random control subjects matched on age and study cohort, and obtained DNA samples from blood or buccal smears from 85% of the eligible cases and 84% of the control subjects. They included genotypes from 214 cases and 449 control subjects, all Caucasian.

RESULTS

The odds ratio of PD was 1.2 (95% CI 0.9, 1.7) for MAOB genotypes G/GG/GA compared with genotypes A/AA, and 1.1 (0.7, 1.8) for COMT genotypes LL compared with HH. The odds ratio (95% CI) was 1.7 (0.7, 3.9) for those with MAOB G/GG and COMT(LL) genotypes compared with those with MAOB A/AA and COMT(HH). There was a strong association between never smoking and PD risk in all groups defined by MAOB and COMT genotypes.

CONCLUSION

The findings do not support a major role of the MAOB intron 13 polymorphism in the development of PD, either by itself or by interacting with smoking.

Specific DNA recognition by the type II restriction endonuclease MunI: the effect of pH

To investigate the effect of pH on sequence-specific binding, a thermodynamic characterization of the interaction of the protein MunI with a specific, and a nonspecific, oligonucleotide was performed. MunI is a type II restriction endonuclease which is able to bind specifically, but loses its enzymatic activity in the absence of magnesium ions. Comparison of the specific and nonspecific interactions at 10 and 25 degrees C shows that the latter is accompanied by a small change in enthalpy, and a negligible change in constant pressure heat capacity. On going through the pH range 5.75-9.0 at 25 degrees C, the affinity of specific complex formation is reduced by 20-fold. The interaction is accompanied by the protonation of groups assumed to be on the protein. Based on the simplest model that will fit the data, two distinct protonation events are observed. At low pH, two groups per protein molecule undergo protonation with a pK(a) of 6.0 and 6.9 in the free and bound forms, respectively. At high pH, a further independent protonation occurs involving two groups with pK(a) values of 8.9 and approximately 10.7 in the free and bound forms, respectively. The change in heat capacity ranges from -2.7 to -1.7 kJ mol(-1) K(-1) in going from pH 6.5 to 8.5. This range of variation of change in heat capacity can be accounted for by the effects of protonation of the interacting molecules. The change in heat capacity, calculated from surface area burial using a previously established relationship (1.15 kJ mol(-1) K(-1)), does not correlate well with the experimentally determined values.